Peronal Inventory Questionnaire

Peronal Inventory Questionnaire
In order to plan the best services for you and/or your family it's important to gather some initial demographic and self-inventory information. Please respond to the following questions to the best of your ability. The more you are able to share about yourself, the better able we'll be to plan for your services together.
Name
Date

MonthDayYear
Today's Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address, if different from above
Preferred Phone
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Do you give us permission to leave a message on your phone?

YesNo
Do you give us permission to communicate via email?

YesNo
Email Address
example@example.com
Do you give us permission to communicate with you via text messaging?

YesNo
Date of Birth

MonthDayYear
Date
Age
SSN
What is your current gender identity? (Check ALL that apply)

MaleFemaleTransgender
Referral Source
Race
Spoken Languages
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.
Insurance Plan
Insured ID or Contract Number
Insured / Subscriber's Employer
Subscriber's Name

First NameMiddle NameLast Name
Subsciber's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Phone Number
Subscriber Date of Birth

MonthDayYear
Date
Subscribers SSN
Secondary Insurance Plan / Program
Secondary Insured ID / Contract
Military History

YesNo
If yes, Highest Rank / Branch of Service
Education Background
Highest Grade Completed
Number Years Undergraduate
Graduate Degree
Occupation
Annual Gross Income
Current Employer(s)
Are you satisfied with your current job/position?

YesNo
Any recent changes in your employment or job responsibilities?

YesNo
If Yes, Explain
Financial Concerns
Previous Employers
Have you had any significant periods of unemployment?

YesNo
If Yes Explain
Current Living Situation
Name of spouse / significant other, if applicable
Phone number for spouse/significant other:
Please enter a valid phone number.
History of Present Relationship (if applicable):
Childrens Names / Ages / Sex / Living Arrangements (if Applicable)
History of Previous Relationships:
Describe the family you grew up in:
Who is the most important person in your life and why?
ReligiousSpiritual Affiliation
People come for therapy / treatment for any number of reasons, most commonly due to specific life stressors, uncomfortable or undesirable symptoms, or major life changes, to name a few. What brings you in for services now?
When did these concerns begin?
What was going on at the time?
Rate your current level of distress on a scale of 1 to 10, with 10 being the highest:
Lowest - 1 2 3 4 5 6 7 8 9 10 - Highest
Has anyone recommended that you seek therapy? If so, who:
How long have you thought about coming in for therapy?
Have there been any obstacles to you making the decision to seek help?
Have there been any recent events or past events that remain unresolved that cause you discomfort pain or discontent? If so, explain:
How would you like your life to look differently in the next 3 - 5 years?
Famiy History of:

SuicideHomocideMental IllnessSubstance AbuseIntellectual Disability
Relevant Medical Background
Do you have concerns about your health?

YesNo
If yes explain
DIsabilities:

YesNo
If yes explain
Family physician
Date of Last Visit:

MonthDayYear
Date
Why?
Pregnant:

YesNoN/A
Prenatal care:

YesNoN/A
Seizures/History of Seizures:

YesNo
Currently Treated?

YesNo
Any Allergies to Medications:

YesNo
Other Allergies
Current Medical Conditions
Current Medications
Medication | Strength/Dosage | Prescriber | Over the Counter
Take Medications as Prescribed:

YesNo
Have you been in therapy before, or had any prior treatment for a mental health condition, including psychiatric hospitalizations.

YesNo
Have you felt and wanted or needed to cut down on your drinking or drug use in the past year?

YesNo
Has anyone objected to your drinking or drug use? OR has your family, a friend, or anyone elsetold you they objected to your alcohol or drug use?

YesNo
Have you ever found yourself preoccupied with wanting to use alcohol or drugs? OR Have you found yourself thinking a lot about drinking or using?

YesNo
Have you ever found yourself preoccupied with wanting to use alcohol or drugs? OR Have youfound yourself thinking a lot about drinking or using?

YesNo
Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger or boredom?

YesNo
Significant Legal History?

YesNo
If Yes Explain
Was your contact with us a result of a requirement by the Courts:

YesNo
If Yes Explain
Have You Ever Experienced a Traumatic Event?

YesNo
If Yes Explain
Abuse History:

NoneSexualEmotionalPhysicalDomesticElder
If Yes to any, Explain
Do you have thoughts and behavior related to:

SuicideHomocideAggression
If Yes, Explain
Is there anything else that you feel its important for your therapist to know about you that hasn't already been addressed? If yes, explain:
Should be Empty:

Peronal Inventory Questionnaire

Education Background

Relevant Medical Background